Immobile, mute, and at risk

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1 Immobile, mute, and at risk Artha Gillis, MD, PhD, and Glen L. Xiong, MD Mr. M has schizophrenia and develops catatonia after being found naked outside his home. Immobility and reduced oral intake increase his risk of medical complications. How do you ensure his safety? How would you handle this case? Visit CurrentPsychiatry.com to input your answers and see how your colleagues responded CASE Nude and mute Mr. M, age 45, is found naked outside his apartment. He has a history of schizophrenia, paranoid type, hypertension, and diet-controlled type 2 diabetes mellitus. His schizophrenia has been treated with ziprasidone, 160 mg/d, but 2 months ago he stopped taking his medication and seeing his psychiatrist. He does not respond to questions from police and is taken to a local emergency department for medical workup of altered mental status. Mr. M is noted to have bilateral conjunctival discharge and a white blood cell (WBC) count of 15,000/mm 3. Vital signs, physical examination, laboratory studies, and head CT are otherwise within normal limits. Mr. M is medically cleared for his 15 th admission to our inpatient psychiatric facility in the last 7 years. He is divorced, has 2 adult sons, and receives Social Security disability benefits. Mr. M is alert but guarded and mute and appears to be internally preoccupied. His mood is euthymic and his facial expressions do not vary much and are similar to a blank stare. His grooming and hygiene are poor, but there is no evidence of delusions or suicidal or homicidal ideation. He paces around the unit or sits in his bed staring straight ahead, occasionally mouthing inaudible words but remaining nonverbal. Mr. M is restarted on his previous dose of ziprasidone and referred to the primary care physician in our inpatient psychiatric facility for further evaluation. His admission vitals and laboratory values show a platelet count of 124,000/mm 3, glucose of 113 mg/dl, triglycerides of 160 mg/dl, high-density lipoprotein of 37 mg/dl, and hemoglobin A 1c of 6%. Mr. M needs help drinking fluids but resists solid foods as well as medications, including lorazepam, 3 mg/d, and most scheduled doses of ziprasidone. On day 3, Mr. M s extremities are rigid and he has poor oral intake. We diagnose Mr. M with catatonia based on his immobility, negativity, and mutism. The authors observations The literature describes >40 signs of catatonia According to DSM-IV-TR, catatonia may occur in the context of schizophrenia, a mood disorder, or a general medical condition. DSM-IV-TR criteria for catatonia include: motor immobility as evidenced by catalepsy or stupor excessive motor activity extreme negativism or mutism peculiarities of voluntary movements as evidenced by posturing, stereotypic movements, or grimacing echolalia or echopraxia. 12 Dr. Gillis is a first-year resident and Dr. Xiong is Assistant Clinical Professor, Department of Psychiatry, University of California, Davis, Sacramento, CA. continued Vol. 9, No

2 Poor oral intake and immobility seen in catatonia may lead to malnutrition, dehydration, pneumonia, or infection 72 December 2010 Table Signs and symptoms of deep vein thrombosis and pulmonary embolism Deep vein thrombosis Swelling of the leg or along a vein in the leg Pain or tenderness in the leg, which may be felt only when standing or walking Increased warmth in the area of the leg that is swollen or in pain Red or discolored skin on the leg Pulmonary embolism Unexplained shortness of breath or pain with deep breathing Chest pain Coughing or coughing up blood Arrhythmia Source: National Heart, Lung, and Blood Institute. What are the signs and symptoms of deep vein thrombosis? Available at: SignsAndSymptoms.html. Accessed November 8, 2010 Only 2 signs are necessary to meet the diagnostic criteria for catatonia. 11,12 Several catatonia rating scales including the Bush- Francis Catatonia Rating Scale (BFCRS) have been found to be highly reliable for screening for and rating the severity of catatonia. Such tools also can be used serially to monitor treatment efficacy. The BFCRS takes 5 minutes to administer; the screen is considered positive if 2 of the first 14 items on the scale are present. 13 Mr. M exhibits immobility and mutism, which are the most common signs of catatonia. In patients with catatonia, poor oral intake may result in malnutrition that often requires parenteral nutrition or intravenous fluids 1,10 and dehydration that may lead to dental caries, gum disease, constipation, and ileus. 1 Pneumonia may occur secondary to atelectasis or buildup of respiratory secretions and possibly aspiration. 7 Vaginal infections may develop secondary to poor hygiene. 1 Immobility and malnutrition may lead to infection and decubitus ulcers. 1 Finally, immobility also may cause urinary incontinence, 2,10 nerve palsies, flexion contractions, and rhabdomyolysis. 1 Which of the following complications of catatonia is most acute and emergent? a) aspiration pneumonia b) flexion contractures c) dental caries/gum disease d) venous thromboembolism e) rhabdomyolysis EVALUATION Venous complications On day 3, Mr. M is referred to a local emergency department, where he is assessed for delirium and dehydration because of increased WBC count and diaphoresis. The medical staff finds bilateral pulmonary embolisms and a deep vein thrombosis (DVT) of his left lower leg. The authors observations Catatonia is associated with an increased risk of venous thromboembolism because of the increased risk of venous stasis and hypercoagulability, both elements of Virchow s triad for thrombogenesis. 1-10,14,15 The third element of Virchow s triad, vascular injury, does not appear to directly increase the risk for thromboembolic events in catatonic states. Catatonia-specific causes for venous stasis include immobility, prolonged use of physical restraints, and sedation as a side effect of antipsychotic use. 16 Causes for hypercoagulability during catatonic states include: increased catecholamine levels during excited states 3 hyperhomocysteinemia secondary to poor diet, smoking, and/or high caffeine consumption 16 increased anticardiolipin and/or antiphospholipid antibody levels secondary to use of specific antipsychotics, such as chlorpromazine and clozapine 16 increased platelet aggregation secondary to hyperprolactinemia caused by low-potency conventional antipsychotics, such as chlorpromazine 16,17

3 increased platelet activation caused by altered levels of platelet serotonin in depressed patients. 18 Patients taking low-potency conventional antipsychotics may have a 7-fold greater risk for thromboembolic events compared with those who do not use these medications. 16 Reducing thromboembolic risk Diagnose catatonia early. Treating symptoms of catatonia early with benzodiazepines (and, in refractory cases, with electroconvulsive therapy) prevents immobility, thereby decreasing the risk of thromboembolic events. 3,11 It may be useful to minimize antipsychotic use. Monitor activity levels. Fatal thromboembolic events may appear early in the course of catatonia before risk factors associated with thromboembolic events are evident. 4 However, these events may be more common when the patient resumes movement. 3 Monitor patients activity status and encourage ambulation throughout treatment. Algorithm Does my patient need venous thromboembolism prophylaxis? Step 1. Assess risk factors for venous thromboembolism and determine risk level score Risk factor Consensus-based Score Immobilization 1 Hormone therapy 1 Obesity (BMI 30 kg/m 2 ) 1 Age 60 to 74 1 Varicose veins/venous insufficiency 1 Dehydration 1 Thrombophilia 1 Expert opinion Treatment with antipsychotics 1 Evidence-based History of deep vein thrombosis or pulmonary embolism Cancer (active/treated) 2 Age 75 2 Acute infection/respiratory disease 2 TOTAL BMI: body mass index 2 Treating symptoms of catatonia early prevents immobility, thereby decreasing the risk of thromboembolic events Monitor vital signs for signs of pulmonary embolism, including hypoxia, tachycardia, tachypnea, and fever. Take serial pulse oximetry and, if indicated, arterial blood gas measurements to monitor hemoglobin oxygen saturation. Be vigilant for other signs and symptoms of pulmonary embolism and DVT (Table). Consider prophylactic treatment. Some studies recommend prophylaxis against thromboembolic events in catatonic patients. 3-6,10,15 These measures include: intravenous fluids nasogastric tube feeding physical examinations to assess for signs of DVT support stockings sequential/pneumatic compression devices Step 2. Determine recommended prophylaxis based on risk level score Risk level score All risk levels Medium risk (4 to 7 points) and/or physical restraint 8 hours High risk ( 8 points) Recommended prophylaxis Source: Adapted from reference 15 Regular physical exercise of lower extremities, sufficient hydration, graduated compression stockings Heparin, 5,000 units every 12 hours, or low molecular weight heparin equivalent until patient is fully mobilized Heparin, 5,000 units every 8 hours, or low molecular weight heparin equivalent until patient is fully mobilized continued Vol. 9, No

4 Fatal thromboembolic events may appear early in the course of catatonia, but are more common when the patient resumes movement physical therapy or range-of-motion exercises complete anticoagulation during immobility, although there are no data that support using anticoagulation medications in catatonic patients who have not yet experienced a thromboembolic event. Consider prophylactic antithrombotic treatment in catatonic patients and other immobile inpatients who have risk factors for thromboembolic events. 9,16 Although it has not been rigorously tested, the Algorithm (page 73) suggested by Malý et al 15 can serve as a guideline for determining the need for prophylaxis against venous thromboembolism in psychiatric inpatient settings. OUTCOME Stable and speaking In the hospital, Mr. M remains immobile and mute for several days. The hospital s psychiatric consult team recommends lorazepam, 3 mg/d, to address his catatonia. Mr. M improves and begins speaking and eating after starting lorazepam, but becomes agitated, banging his head against walls and threatening to jump out the window. Because this puts him at risk for trauma, Mr. M is not a good candidate for warfarin therapy, and an inferior vena cava filter is placed on an emergency basis. Later, a Dobhoff tube is placed for feeding and administering oral medications. Mr. M s catatonic state gradually improves and he begins to respond to the staff with short phrases, eats all of his food, and accepts oral medications. He is transferred back to our inpatient psychiatric facility with haloperidol, 10 mg/d, lorazepam, 3 mg/d, and benztropine, 2 mg/d, in addition to sulfacetamide eye drops for bilateral conjunctivitis. At our facility, we start him on warfarin, 5 mg/d, and closely monitor his international normalized ratio levels, with a plan to remove the inferior Available Online FREE 2.0 CME credits Available at CurrentPsychiatry.com Click on Supplements/CME Effective Strategies for Patients With Complex Depression in Psychiatric Practice Switch or augment? Lessons from STAR*D Andrew A. Nierenberg, MD, Associate Director, Depression Clinical and Research Program, Co-Director, Bipolar Clinic and Research Program, Massachusetts General Hospital; Professor of Psychiatry, Harvard Medical School, Boston, Massachusetts Switching, combination, and augmentation strategies for major depressive disorder George I. Papakostas, MD, Director, Treatment-Resistant Depression Studies, Massachusetts General Hospital; Associate Professor of Psychiatry, Harvard Medical School, Boston, Massachusetts Major depressive disorder and other medical illness: A two-way street Philip R. Muskin, MD, Professor of Clinical Psychiatry, Columbia University; Chief of Service: Consultation-Liaison Psychiatry, Department of Psychiatry, Columbia University Medical Center; Research Psychiatrist, New York State Psychiatric Institute, New York, New York This supplement was sponsored by SciMed and supported by an educational grant from AstraZeneca. It was peer reviewed by.

5 vena cava filter after 6 months of anticoagulation therapy. Mr. M remains at our facility for 3 weeks to stabilize his medications and is discharged to his apartment. Six months after being discharged from our facility, Mr. M is stable at an intensive outpatient mental health program. References 1. Caroff SN, Mann SC, Francis A, et al, eds. Catatonia: from psychopathology to neurobiology. Arlington, VA: American Psychiatric Publishing, Inc.; Gangadhar BN, Keshavan MS, Goswami U, et al. Cortical venous thrombosis presenting as catatonia: a clinicopathologic report. J Clin Psychiatry. 1983;44: McCall WV, Mann SC, Shelp FE, et al. Fatal pulmonary embolism in the catatonic syndrome: two case reports and a literature review. J Clin Psychiatry. 1995;51: Morioka H, Nagatomo I, Yamada K, et al. Deep venous thrombosis of the leg due to psychiatric stupor. Psychiatry Clin Neurosci. 1997;51: Lachner C, Sandson NB. Medical complications of catatonia: a case of catatonia-induced deep venous thrombosis. Psychosomatics. 2003;44: Woo BK. Basal ganglia calcification and pulmonary embolism in catatonia. J Neuropsychiatry Clin Neurosci. 2007;19: Regestein QR, Alpert JS, Reich P. Sudden catatonic stupor with disastrous outcome. JAMA. 1977;238: Suzuki K, Takamatsu K, Takano T, et al. Safety of electroconvulsive therapy in psychiatric patients shortly after the occurrence of pulmonary embolism. J ECT. 2008;24: Tsao C, Nusbaum A. Successful ECT course for catatonia after large pulmonary embolism and placement of inferior vena cava filter. Gen Hosp Psychiatry. 2007;29: Barbuto J. Preventing sudden death during a catatonic episode. Hosp Community Psychiatry. 1983;34: Taylor MA, Fink M. Catatonia in psychiatric classification: a home of its own. Am J Psychiatry. 2003;160: Diagnostic and statistical manual of mental disorders, 4 th ed, text rev. Washington, DC: American Psychiatric Association; Related Resources Fink M, Taylor MA. Catatonia: a clinician s guide to diagnosis and treatment. Cambridge, United Kingdom: Cambridge University Press; Snow V, Qaseem A, Barry P, et al, and American College of Physicians; American Academy of Family Physicians Panel on Deep Venous Thrombosis/Pulmonary Embolism. Management of venous thromboembolism: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med. 2007;146(3): Drug Brand Names Benztropine Cogentin Chlorpromazine Thorazine Clozapine Clozaril Haloperidol Haldol Disclosure Lorazepam Ativan Sulfacetamide Sulamyd Warfarin Coumadin Ziprasidone Geodon The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products. 13. Bush G, Fink M, Petrides G, et al. Catatonia I. Rating scale and standardized examination. Acta Psychiatr Scand. 1996; 93(2): Lal S, Bleiman M, Brown GN. Pulmonary embolism in psychiatric patients. J Am Geriatr Soc. 1966;14: Malý R, Masopust J, Hosák L, et al. Assessment of risk of venous thromboembolism and its possible prevention in psychiatric patients. Psychiatry Clin Neurosci. 2008;62: Higg S, Jönsson AK, Spigset O. Risk of venous thromboembolism due to antipsychotic drug therapy. Expert Opin Drug Saf. 2009;8: Wallaschofski H, Eigenthaler M, Kiefer M, et al. Hyperprolactinemia in patients on antipsychotic drugs causes ADP-stimulated platelet activation that might explain the increased risk for venous thromboembolism: pilot study. J Clin Psychopharmacol. 2003;23(5): Arnone D, Hansen L, Davies G. Pulmonary embolism and severe depression. Am J Psychiatry. 2009;159: Consider prophylactic treatment in catatonic patients and other immobile inpatients who have risk factors for thromboembolic events Bottom Line Catatonia may be characterized by immobility and reduced oral intake that can lead to serious medical complications. Maintain a high index of suspicion for venous thromboembolism in psychiatric patients with catatonia and initiate prophylaxis against or treatment of venous thromboembolism to prevent potentially fatal pulmonary emboli. Vol. 9, No